New York State Department of Health Bureau of Emergency Medical Services EMT-Intermediate Curriculum Overview I. PREPARATORY A. Foundations of the EMT-Intermediate This unit covers, in an overview format, the most significant aspects of the following topics: EMS Systems/Role and Responsibilities, Medical Direction, Well-Being (including body substance isolation), Illness and Injury Prevention, Medical/Legal Issues, and Ethical Issues. B. Overview of Human Systems/Roles and Responsibilities This overview of human systems includes the major aspects of anatomy and physiology including body organization, anatomical terminology, cell transport mechanisms, metabolism, and tissue types. All body systems are discussed with, emphasis on the nervous and cardiac systems. Basic fluid and electrolyte information is also included. C. General Pharmacology This unit is a review of General Pharmacology unit of the New York State EMT-Basic curriculum (Lesson 4-1). It will include medications which may be carried on the ambulance and medications the EMT-Intermediate may assist the patient with administering in the field. D. Intravenous Access This unit is designed to teach safe and precise venous access. Medical direction is discussed in this unit relative to medical/legal aspects of invasive procedures and medication administration. Medical asepsis, body substance isolation (BSI) procedures for intravenous access, and disposal of contaminated items and sharps, are included in the module. The discussion of venous access includes equipment and preparations used for obtaining peripheral and central venous routes, as well as indications, precautions, procedures, and general principles. The section on enteral and parenteral medication administration, and administering medications by inhalation, includes equipment and preparations, indications, techniques, precautions, procedures, and general principles. The unit discusses the purposes for obtaining a blood sample, then lists equipment and preparations, locations from which to draw a sample, procedures, and complications. II. AIRWAY MANAGEMENT AND VENTILATION This unit is designed to teach how to establish and/or maintain a patent airway, and oxygenate and ventilate a patient. The fact that each of these topics occupies a separate unit emphasizes their significance. The unit reviews the anatomy and physiology of the respiratory system and presents the upper and lower airways, differences in the pediatric airway, and lung/respiratory volumes in detail. Other topics include: ventilation and respiration, measurement of gases, and causes of decreased oxygen concentrations in the blood. The discussion of the pathophysiology of airway obstruction (laryngeal spasm and edema, aspiration, etc.) helps the student understand its negative impact on a patient's condition. Airway management includes assessment, manual maneuvers, adjunctive equipment (oral and nasal airways, endotracheal tube, lighted stylet and multilumen airways), and procedures (orogastric/nasogastric decompression, orotracheal/nasotracheal intubation, digital intubation). Other topics include extubation, pediatric endotracheal intubation, and considerations for special situations (stomas, facial injuries, etc.). The section on oxygenation identifies oxygen sources, delivery equipment and devices, and special considerations for patients with stoma. Various suctioning devices, adjunctive equipment, and techniques are also described. Ventilation includes recognition and identification of respiratory compromise, techniques, and adjunctive equipment. The discussion of ventilation covers basic ventilation adjuncts (bag-valve- mask and pocket mask), the automatic transport ventilator, cricoid pressure, and ventilating pediatric patients and patients with stomas. III. PATIENT ASSESSMENT A. History Taking This unit is designed to teach the students a more complete approach to history taking. The SAMPLE and OPQRST mnemonics are presented as standardized methods for gathering a history. This section focuses on components of the patient history, current health status of the patient, techniques of history taking, and gathering information about the present illness. A section also emphasizes techniques to overcome special challenges including silence; overly talkative patients; anxiousness; angry and hostile patients; intoxication, crying, or depressed patients; sexually attractive or seductive patients; confusing behavior or history; limited intelligence; language barriers; hearing problems; and blind patients. B. Techniques of Physical Exam This unit provides the core material necessary for conducting a patient assessment. Comprehensive techniques of physical examination are presented by anatomical regions: skin, head, eyes, ears, nose, throat, neck, chest, abdomen, genitalia, posterior body, and extremities. Other topics discussed include mental status, general survey, vital signs and neurologic exam. Each anatomical section discusses specific techniques of physical examination, including sections on inspection, auscultation, palpation, and percussion, with special considerations for how and what to examine in each body area or system. The units focus on normal findings, but significant abnormal findings are also identified. The unit aims, by ensuring that the students can understand and identify "normal findings", to make certain that they will be more capable of identifying "abnormal findings". Students must be taught the proper techniques of physical examination in order to apply the appropriately to the process of patient assessment. As an example, when a student determines the need to examine the head as a part of the detailed examination, they already will have learned the proper techniques of examining the head and understand the normal findings. Thus, the student is provided the proper tools to conduct a physical examination and extract what is most important based on the condition of the patient, while maintaining a holistic understanding. C. Patient Assessment The terminology and phases of assessment have been standardized to those of the EMT-Basic curriculum. However, the content is more comprehensive in some areas, such as the detailed physical exam. The components of patient assessment are scene size-up, initial assessment, focused history and physical exam for both the medical and the trauma patient, detailed physical exam, and on-going assessment. The scene size-up focuses primarily on keeping the EMT-Intermediate safe. Information presented in the earlier Well-Being of the EMT-Intermediate section is reinforced in this section presenting the need to establish body substance isolation and scene safety as one of the first priorities when arriving at a scene. Other components include determining the mechanism of injury or nature of illness, the number of patients, and whether any additional resources are required. The initial assessment is designed to identify any immediately life threatening injuries or conditions, primarily those affecting the airway, breathing, or circulation status of the patient. These injuries or conditions must be managed immediately when found since they will lead to sudden or continuous deterioration, and potentially the death of the patient. A general impression is a quick scan of the body conducted to determine any obvious life threats that require immediate management, such as a large sucking chest wound or an arterial bleed. A baseline mental status is established, followed by assessment of the airway, breathing, and the circulation, the latter includes skin color, temperature, condition, and any major bleeding that may not have been identified in the general impression. Based on the information collected, a priority status is established that drives decisions regarding further assessment and expeditious transporting. The focused history and physical examination is designed to identify all other injuries or conditions. It is divided into separate sections for trauma and medical patients. Trauma patients with a significant mechanism of injury or altered mental status will require a rapid trauma assessment designed to identify all other life threats such as intra-abdominal bleeding, chest wounds, head injury, and any other immediately life-threatening conditions. The rapid trauma assessment is a systematic head-to-toe exam employing techniques of inspection, palpation, auscultation, and percussion. Like the initial assessment, management for the life threats found in the rapid trauma assessment is conducted as the conditions or injuries are found. If the patient is responsive and does not have a significant mechanism of injury, a focused exam is conducted on the specific area of injury. The student must refer back to the techniques of physical exam to determine the most appropriate methods of examination. History and baseline vitals signs are obtained as part of the assessment. The focused history and physical exam for the medical patient is based on the patient's level of responsiveness. In the responsive patient, the history is conducted as a priority, followed by physical examination of the areas of complaint and related body systems. A rapid medical assessment, (similar to the rapid trauma assessment) is performed on the unresponsive medical patient, followed by history gathering. Baseline vital signs are obtained for both assessments. The detailed physical exam is based on the patient's condition and the time until arrival at the health care facility. The detailed exam will use the information presented